The Basics
TAKING CARE OF OUR PATIENTS
At Clinica, taking good care of our patients starts long before you enter the exam room. Beginning with your first phone call to us, we want to provide you with the best service possible. This includes providing you an appointment with our financial screening staff who specialize in making sure that you get all of the financial assistance you can. We will walk you through the process of applying for Medicaid, the Children’s Health Plan Plus (CHP+) or one of the insurance plans available through Colorado’s insurance marketplace.
Call 303-650-4460 to make an appointment with one of our Enrollment Specialists who can help determine what programs you may qualify for that can lower your healthcare cost.
REQUESTING PATIENT RECORDS
Patients or authorized healthcare providers may request copies of patient health records. NOTE: It may take up to two (2) weeks for Clinica Family Health to process and provide copies of the patient’s records. A member of Clinica’s staff will contact you when records are ready.
To request protected patient health information:
- Click to Download the Request of Information (ROI) Form;
- Complete the form by providing the required information; and
- Fax the completed form to the patient’s main Clinica medical or dental clinic using the fax numbers listed below:
FAX NUMBERS MEDICAL CLINICS
Lafayette Clinic Fax: 303-926-0363
Pecos Clinic Fax: 303-650-6830
People’s Clinic Fax: 720-565-4250
Thornton Clinic Fax: 720-929-1421
Westminster Clinic Fax: 303-546-4000
FAX NUMBERS DENTAL CLINICS
Thornton Dental Clinic Fax: 720-207-0171
Pecos Dental Clinic Fax: 720-206-0437
CLINICA IS TEXTING NOW!
Clinica is trying out a new system that can text appointment reminders to you! If you provide us with your cell phone number — and are a patient of the Pecos Clinic blue pod, the Thornton Clinic yellow pod or one of our dental clinics — we can send you a text reminder of your next appointment. You can choose to opt out of this service at any time. Please let us know what you think of this new appointment reminder system. Thanks!
Terms and Conditions:
Messages and data rates may apply. Text HELP to 622622 to receive help, Text STOP to 622622 to opt out. Message frequency depends on account settings. Participating carriers include T-Mobile®, Verizon Wireless, AT&T, Sprint, Boost, US Cellular®, MetroPCS and Cricket.
HOW TO ENROLL AS A NEW PATIENT WITH CLINICA
Enrollment screening is a process of determining which payment program you and your family qualify for or how much you should pay on Clinica’s sliding-fee scale.
Because your financial situation can change, we require patients to update their financial assistance eligibility every year.
DOCUMENTS NEEDED TO APPLY FOR FINANCIAL ASSISTANCE
Bring all necessary documents to your appointment. We will not be able to help determine what financial assistance you qualify for if you do not bring the necessary documents. If you cannot bring one or more of the documents, please cancel your appointment and reschedule once you have all the documentation.
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- Picture ID for all adult applicants.
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- Social Security numbers for all family members (if applicable).
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- Legal Permanent Resident Card if resident of U.S., or work permit (if applicable).
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- Proof of address under patient’s name such as public service bills or other bills. Statement date should be for previous or current month.
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- Insurance cards, for example: Medicaid, Medicare or private health insurance, etc.
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- Proof of unearned income, for example: child support, SSDI, SSI, or unemployment letter.
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- If self-employed, bring previous month business ledger. The ledger needs to reflect total earning for the month and total business expenses for the same month.
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- If pregnant, need to know expected delivery date. Bring picture ID or birth Certificate and Social Security card (if applicable).
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- Children under age 18: Passport, birth certificates, Colorado ID or school ID (if applicable).
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- If paid with check stubs, all check stubs from previous month. If you are paid with cash please provide a signed and dated letter from your employer. Letter needs to state the hours worked per week, pay per hour, pay frequency and gross income from the last month. Make sure your employer listed his/her phone number and business address.
- If shared residency: Bring a signed, dated letter from the person you live with. The letter should include the person’s name, address and, phone number. You will also need to bring a bill dated the previous or current month from the person writing the letter.
WHERE TO ENROLL AS A NEW PATIENT WITH CLINICA
ENROLLMENT & FINANCIAL ASSISTANCE LOCATIONS & HOURS
Lafayette Clinic
1735 S Public Rd. 1st Floor,
Lafayette, CO 80026
Call for Appointment: 303.650.4460
Enrollment Walk-In Hours:
Monday – Thursday: 8AM – 11AM, 1PM – 4PM (closed for lunch from 11AM – 1 PM)
Friday: 8AM – 11AM, 1:30PM – 3:30PM (closed for lunch from 11AM – 1:30PM)
Saturday and Sunday: Closed
Pecos Clinic
1701 W. 72nd Ave.
Denver, CO 80221
Call for Appointment: 303.650.4460
Enrollment Walk-In Hours:
Monday – Thursday: 8AM – 11AM, 1PM – 4PM (closed for lunch from 11AM – 1 PM)
Friday: 8AM – 11AM, 1:30PM – 3:30PM (closed for lunch from 11AM – 1:30PM)
Saturday and Sunday: Closed
People’s Clinic Boulder
2525 13th St.
Boulder, CO 80304
Call for Appointment: 303.650.4460
Enrollment Walk-In Hours:
Monday – Thursday: 8AM – 11AM, 1PM – 4PM (closed for lunch from 11AM – 1 PM)
Friday: 8AM – 11AM, 1:30PM – 3:30PM (closed for lunch from 11AM – 1:30PM)
Saturday and Sunday: Closed
Thornton
8990 N. Washington St.
Thornton, CO 80229
Call for Appointment: 303.650.4460
Enrollment Walk-In Hours:
Monday – Thursday: 8AM – 11AM, 1PM – 4PM (closed for lunch from 11AM – 1 PM)
Friday: 8AM – 11AM, 1:30PM – 3:30PM (closed for lunch from 11AM – 1:30PM)
Saturday and Sunday: Closed
Westminster
8510 N Bryant St. 2nd Floor,
Westminster, CO 80031
Call for Appointment: 303.650.4460
Enrollment Walk-In Hours:
Monday – Thursday: 8AM – 11AM, 1PM – 4PM (closed for lunch from 11AM – 1 PM)
Friday: 8AM – 11AM, 1:30PM – 3:30PM (closed for lunch from 11AM – 1:30PM)
Saturday and Sunday: Closed
YOUR RESPONSIBILITIES AS OUR PATIENT
FOLLOW CLINIC RULES. Follow rules including the consideration of the rights of other patients and Clinica staff. Please assist with the control of noise and observe the no smoking policy.
INFORM. Please give full and honest information. This includes giving necessary records for registrations, billing, and ability to pay.
MEDICATION SAFETY. Please keep and share information on all medications you take, including those from other health care providers. If you currently take medications, please bring all your medication bottles to each appointment. Many health care mistakes are made because patients don’t share all the medications they are taking.
REPORT CHANGES. Report any changes in your condition, symptoms, and allergies to your provider.
FOLLOW INSTRUCTIONS. Follow your health care provider’s instructions. If you have any questions, please ask. Accept the results if you refuse treatment or do not follow the health care provider’s instructions.
PARTICIPATE IN YOUR OWN HEALTH SAFETY. We encourage you to help us by reporting any concerns you have about you and your family’s safety at Clinica. Report any concerns to a staff member or write them on a “Your Comment’s Count” card.
BE ON TIME. Arrive on time for your appointment.
CANCEL APPOINTMENTS. If you are not able to keep a scheduled appointment, please cancel that appointment prior to the scheduled appointment time. We ask that you cancel with as much advanced notice prior to the appointment as possible.
REPORT EMERGENCIES. Should you receive emergency care from another health care provider, please let us know as soon as possible, during our normal business hours.
SHOW INSURANCE CARD AND PCP CARD. Show your insurance and Clinica Card (including your Medicaid ID card) at each visit.
FINANCIAL SCREENING. Complete the financial screening process by bringing all insurance, income documentation, and other requested information to the financial screening staff within 30 days of your first visit or when your insurance expires. Your care may be terminated if you do not meet with a financial screener within 30 days.
PAY BILLS. Your fees will be adjusted so that they are affordable for you. Please pay your co-pay and bills promptly.
YOUR RIGHTS AS OUR PATIENT
ACCESS. Appointments are provided within a reasonable period of time, with discount programs available for individuals based on family size and income. You will not be denied health care services due to your inability to pay. Clinica’s policy regarding accommodation and non-discrimination.
DIGNITY. Care is provided in a manner that respects your individuality and dignity. This includes being told by your care givers what your condition is, what treatment they recommend, how they expect your condition to change, and what follow up care is needed.
PRIVACY. All physical exams, interviews, and discussions about your health will occur privately and your health records will be handled confidentially. Clinica Family Health will handle all of your records in compliance with federal privacy laws (HIPAA) and will abide by the terms of our Notice of Privacy Practices.
EMPLOYEE IDENTIFICATION. You have the right to know the names, professional status, and experience of the staff providing your care.
CONSENT. Consent for treatment will be requested by our medical staff before any procedure is performed. The procedure and its value, risks, and other options for treatment will be explained.
REFUSAL OF TREATMENT. You have the right to refuse any care recommended. You have the right to change your mind before undergoing a procedure for which you have given your consent.
ACCESS TO RECORDS. You may review or receive a copy of your medical or dental record within 30 days of your written request. Complaints about your access to records can be addressed to the Colorado Department of Public Health and Environment.
RESEARCH. Before any experimental treatment and/or test you will be provided with information and an opportunity to consent to the treatment or test.
BILLS. You have a right to an explanation of all charges and sliding fee scale adjustments.
FILE A COMPLAINT. You have the right to file a complaint if you are not satisfied with any aspect of your care. You can file a complaint by contacting Clinica Family Health or Health and Human Services.
USE OF YOUR HEALTH INFORMATION. Clinica Family Health is permitted to use or disclose your health information for the purposes of treatment, payment or health care operations, disclosures required by law, and when the healthcare information that is released does not include any identifiable information. For details on how we use your protected health information, please refer to our Notice of Privacy Practices
Phone: 303.665.3036 Ext.1550
TDD: 800.659.2656
Email: 504Coordinator@clinica.org
For information on notice of nondiscrimination, visit:
http://wdcrobcolp01.ed.gov/CFAPPS/OCR/contactus.cfm
For the address and phone number of the office that serves your area call: 800.421.3481.
Clinica Family Health Provides:
Free aids and services to people with disabilities to communicate effectively with us, such as qualified sign language interpreters and written information in other format (large print or other formats).
Free language services to people whose primary language is not English, such as qualified interpreters and information written in other languages. If you need these services, contact our Communication Center to request assistance at 303.650.4460. If you believe Clinica has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, sex, sexual orientation, or gender identity, you can file a grievance with the Civil Rights Coordinator by mail at Civil Rights Coordinator, Clinica Family Health, 1345 Plaza Court N., Suite 1A, Lafayette, CO 80026. You may call 303.665.3036, ext 1550 or (TDD) 800.659.2656. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.
You may also file a civil rights compliant with the U.S. Department of Health and Human Services, Office of Civil Rights at www.orcportal.hhs.gov; or by mail at U.S. Dept of Health and Human Services, 200 Independence Ave, SW Room 506F, HHH Building Washington, DC 20201; or by phone at 800.368.1019 or (TDD) 800.537.7697.
NOTICE OF PRIVACY PRACTICES
This notice describes how medical information about you may be used and disclosed, and how you can get access to this information. Please review it carefully.
I. UNDERSTANDING YOUR HEALTH INFORMATION
Each time you visit our community health center, we create a record of your visit. This record usually contains your name and other information that may identify you, your symptoms, examination and test results, diagnoses, treatment, plan for future health care, and financial information. This record is sometimes referred to as your “medical record” or “medical chart.” This record allows:
- Doctors, nurses, and other health professionals to plan your treatment;
- Our community health center to obtain payment for services we provide to you from health plans, Medicaid, or you; and
- Our community health center to measure the quality of care provided to you.
As in the past, we are committed to keeping your health information confidential. We are required by law to maintain the privacy of your health information and to inform you of our legal duties and privacy practices with respect to your health information. We are required to abide by the terms of this notice, although we reserve the right to change the terms of this notice and will provide you with a revised version via or websites or in person should the terms change. You may request a copy of the current notice at any time. We will not use or share your health information without your written permission, except as stated in this notice.
II. HOW WE WILL USE AND GIVE OUT YOUR HEALTH INFORMATION
A. TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS
We will use and share your health information to provide you with health care treatments, to get paid for our services, and to help us operate our community health center. For example:
We will share your health information with health care professionals not on our staff, such as other healthcare providers and hospital staff, who help care for you. This information may be shared via fax, paper or electronic formats. We also participate in an organized health care arrangement and a health information exchange (Colorado Regional Health Information Organization or CORHIO) that enables healthcare providers to share a database containing your health information for treatment purposes and enables the delivery of better, more efficient care to you. However, you may opt out of participation in CORHIO at any time by notifying our staff, who will then provide you with the forms to do so.
We may send a bill to your health insurance plan or to you to obtain payment for services rendered.
We may use your medical record to review our performance and make sure you receive quality health care and/or to conduct training or compliance functions/activities.
B. OTHER USES AND DISCLOSURES ALLOWED OR REQUIRED BY LAW
We may use or disclose your health information for the following purposes under limited circumstances:
- To people who are involved in your care or who help pay for your care (e.g., your family, close personal friends, or any other person chosen by you) to notify them of your location, general health, and to assist you in your health care (such as to pick-up medicine or help with follow-up care);
- To government agencies that oversee our community health center (such as license and certification inspectors), and/or for specialized government functions, such as military and veteran’s activities, national security and intelligence activities, and protection of public officials;
- To government agencies that have the right to receive and collect health information (such as to control disease outbreaks). We also share health information with the Colorado Immunization Information System (CIIS), which is a confidential database housing immunization data for Coloradans. You may opt out of participation in CIIS at any time by notifying our staff, who will provide you with the forms to opt out;
- When we are ordered by a court or judge;
- To workers’ compensation programs when your health problem is from a work-related injury;
- When law enforcement requests information (such as to prevent danger or injury);
- To report information related to victims of abuse, neglect, or domestic violence or other public health-related permitted uses or disclosures;
- To coroners and funeral directors to allow them to carry out their duties upon your death, and/or for cadaveric organ, eye, or tissue donation and transplantation purposes;
- To organ donor agencies (subject to applicable laws);
- To avoid a serious threat to the health or safety of yourself or others;
- To notify or assist in notifying your family, a personal representative, another person responsible for your care, or disaster relief authorities of your location, condition, or death.
- To contact you about appointment reminders, new treatments, or medicines that may help you;
- For the purpose of research under limited circumstances;
- Through business associates or other contractual arrangements. Some services in our organization are provided through contracts and/or agreements with business associates and other healthcare organizations. Examples include physician services in the emergency department and radiology, mental health services, laboratory and diagnostic services, and other organizations who help to improve the quality of your health and healthcare experiences or assist with our back-office operations (e.g., billing, information technology, etc.). When these services are contracted, we may disclose your health information to our business associates so that they can perform the job we have asked them to do. So that your health information is protected, we require business associates to safeguard your information appropriately.
- We may use medical information about you to contact you in an effort to raise money for the clinic and its operations. If you are contacted in our fundraising efforts, you will have the opportunity to opt out of receiving further fundraising communications from us.
- For any other purpose required or permitted by law.
C. OTHER USES AND DISCLOSURES REQUIRING YOUR WRITTEN PERMISSION
Except as stated above, we will use or give out your health information only after obtaining your written permission on an authorization form. You may revoke your authorization at any time by notifying us in writing that you wish to do so.
III. YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION
Subject to certain legal limits, you have rights regarding the use and disclosure of your health information, including the right to:
Request limits or restrictions on uses of your health information in certain circumstances. However, we are not required to comply with requests in all cases. To request restrictions, you must make your request in writing to Clinica’s HIPAA Privacy Officer. In your request, you must tell us: (1) what information you want to limit; (2) whether you want to limit our use, disclosure, or both; and (3) to whom you want the limits to apply.
- Receive confidential communications about your health information.
- Inspect and copy your health information.
- Request a change or amendment to your health information.
- Receive a record or accounting of how we have used or disclosed your health information.
- Obtain a copy of this Notice of Privacy Practices.
- You have the right to receive notice from us of a breach of your unsecured protected health information.
IV. QUESTIONS, CONCERNS, OR COMPLAINTS
If you have any questions or wish to discuss any of the information in this Notice of Privacy Practices, please contact the HIPAA Privacy Officer at 1735 S. Public Rd., Lafayette, CO, 80026. You can also call our HIPAA Privacy Officer at (303) 650-4460.
If you believe your privacy rights have been violated, you may file a complaint with our community health center or the Secretary of the Department of Health and Human Services. To file a complaint with our community health center, submit a written statement to the HIPAA Privacy Officer at 1735 S. Public Rd., Lafayette, CO, 80026. For information on how to file a formal HIPAA privacy complaint directly with the Department of Health and Human Services go to: https://www.hhs.gov/hipaa/filing-a-complaint/complaint-process/index.html. We will not retaliate against you for filing a complaint.
Pricing for the 15 most common services we provide
Colorado Law requires us to post the full-fee price for the 15 most common services we provide. These are not necessarily the actual prices you will end up paying.*
The prices listed below are an estimate of what you might pay if:
- You do not have insurance (including Medicaid and Medicare);
- The service isn’t covered by your insurance; or
- You are not enrolled in Clinica’s Discount Program or other program offered at Clinica Family Health.
Most people who receive the services noted below at Clinica do not pay the prices listed.
CPT | Full Fee | Service Description |
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99214 | $228.77 | Office/Outpatient Visit, Establish, Detailed |
99213 | $157.85 | Office/Outpatient Visit, Establish, Moderate |
81002 | $26.84 | Urinalysis, Non-automated, w/o Scope |
D1206 | $1.00 | Topical Application of Fluoride Varnish |
D1351 | $50.00 | Sealant – Per Tooth |
90688 | $47.10 | Flu Vacc 4 Val 0.5 mL Dosage IM |
83036 | $77.97 | Hemoglobin A1C |
D0190 | $15.91 | Screening of a Patient |
81025 | $39.67 | Urine Pregnancy Test |
82962 | $25.60 | Glucose Blood Test |
99393 | $210.63 | Preventive Checkup, est, 5-11 yrs |
D0120 | $40.00 | Periodic Oral Evaluation – Establish Patient |
85018 | $21.04 | Blood Count, Hemoglobin |
90715 | $104.17 | TDAP 7 Years and Older |
99392 | $211.34 | Preventive Checkup, est, 1-4 yrs |
GOOD FAITH ESTIMATES FAQs
What is the new requirement?
Beginning on Jan. 1, 2022, all community health centers and most other health care providers must give all uninsured or self-pay patients an estimate of the cost of their care prior to their appointment. This mandate comes from the federal No Surprises Act, which was passed in December 2020. These cost estimates, also called Good Faith Estimates (GFEs), summarize a patient’s total out-of-pocket expenses for the care they will receive at the specified appointment. GFEs must be provided to qualifying patients who schedule an appointment at least three business days in advance or to any patient specifically requesting a GFE.
Are GFEs optional?
Patients cannot opt out of these estimates, and Clinica must provide them.
Which patients must be provided a GFE?
All uninsured and self-pay patients must be provided a GFE for their visit as long as they:
- Schedule an appointment for that service at least three business days in advance.
- Request a GFE (or otherwise ask about the costs of the service) even without scheduling an appointment.
- Have insurance but it does not cover the service they are seeking (e.g., they only have medical coverage but are inquiring about a dental service).
- Have a short-term, limited-duration plan.
- Are underinsured and indicate that they do not plan to submit a claim to their insurer but will pay for the service entirely out-of-pocket.
What information is included in the GFE?
A GFE must provide the following information:
- The primary service being provided to the patient during the visit or “period of care.”
- The items and/or services that are “reasonably expected” to be provided “in conjunction with the primary service” for which Clinica, or an outside provider, has a separate charge. For example, if a patient schedules an appointment for suspected strep throat, the GFE would include an office visit, a lab test (if there is a separate charge for that) and a generic medication.
- The exact charge for the service(s) the patient will be receiving related to the appointment.
The services listed on the GFE will be based on the information available at the time it is requested or generated. The GFE is not required to cover unanticipated care that is not reasonably expected or results from unforeseen events.
What is the “period of care” for a GFE?
In most cases, the “period of care” is a single day. However, if a patient receives a single service that requires returning to the clinic to receive full service (e.g., the two-dose HPV vaccine), then the period of care should encompass both dates. Also, if the patient will have lab work done on a different day and those services are scheduled by Clinica, then the period of care must include both dates.
What if the cost of an item or service is incorrect on my GFE?
Patients whose charges are more than $400 above the cost estimate can pursue a dispute resolution process to get their charges reduced. To pursue a dispute resolution, contact our Billing Department at (303)827-7102.
Will Clinica staff be required to ask me if I am uninsured or self-pay to determine if I should receive a GFE?
Yes. The new federal law requires that health care providers, or a member of their team, ask every person who schedules an appointment (or asks about the cost of their care) if they are:
- uninsured for that service
- are self-pay (they do not plan to submit a claim or their insurance doesn’t cover the service)
How will I receive my GFEs?
You will receive GFEs through the patient portal or by standard mail (US Postal System). All GFEs will be stored in the patient’s chart for six years for future reference.
Can I ask for a GFE during an appointment?
If you ask ask for a cost estimate at the time of service, you will be directed to Clinica’s Billing Department at (303)827-7102.
What if I have questions about my GFE?
If you have additional questions after receiving their GFE, you can contact the Billing Department at (303)827-7102.
Must costs for dental and vision services (e.g., dentures, glasses frames, lenses, etc.) be included in the GFE?
Yes. GFE rules apply to “items or services such as those related to dental health, vision, substance use disorders and mental health.”
MY CLINICA CONNECTION
We know there are times when you want to talk with your health care provider, but you don’t necessarily need an appointment.
Sometimes you have a quick question, want to check on lab results or get a copy of immunization records.
We have an easy and convenient way for you to do that. It’s called My CLINICA Connection. With My CLINICA Connection, you have a secure way to login and e-mail your provider about non-urgent matters, request medication refills on-line, print copies of your records and much more.
Getting enrolled to use My CLINICA Connection is free and easy. Ask any check-in desk staff person or financial screener to help you enroll next time you are in one of our clinics. My CLINICA Connection puts your health information at your fingertips when you want it!
If you are already enrolled in My CLINICA Connection, click the blue button below to log-in.
FAX NUMBERS FOR OUR CLINICS
Alpine: 720-206-0441
Gilpin: 720-565-4134
Lafayette: 720-565-4131
Nederland: 720-565-4133
Pecos: 720-565-4128
People’s: 720-565-4132
Thornton: 720-565-4129
Westminster: 720-565-4130